经胆管192Ir内照射对胆管、肝脏放射损伤的实验研究

目的 探讨经胆管192Ir内照射的安全性、可行性以及有效治疗范围,为肝门部胆管癌经胆管192Ir内照射提供理论依据.方法 取雄性健康杂种犬16只,据照射剂量随机分成4组,每组4只.内照射前从犬肝边缘切取1 cm3大小肝组织作对照研究.术中将近距离治疗施源器经胆囊送入胆囊管与肝总管汇合处并用金属夹固定,根据预先设定的剂量进行胆管内照射.10 d后处死动物,取被照射胆管中央部分长约5 mm胆管,及距离胆管壁由近及远按设计距离分别取1 mm3大小肝组织,制备光镜切片,作HE染色;同时用2.5%戊二醛固定后常规制备电镜切片.光镜下观察胆管及周围肝组织的放射损伤并对损伤程度评分.电镜下观察肝组织超微结构损伤变化并计数凋亡肝细胞.结果 经胆管192Ir内照射30 Gy时,胆管损伤达部分肌层;50 Gy时,胆管仅存外膜;60 Gy时,胆管出现全层坏死.胆管周围肝组织放射损伤随剂量增加而加重.在胆管最大安全耐受剂量50 Gy时,距胆管0～15 mm处肝细胞核出现不可逆性改变.结论 正常胆管对192Ir内照射有良好的耐受性.在胆管最大安全耐受剂量50 Gy时,经胆管192Ir内照射有效的治疗范围可达15 mm.     

CT-gesteuerte Brachytherapie

PURPOSE: To assess safety and efficacy of CT-guided brachytherapy of liver malignancies. PATIENTS AND METHODS: 21 patients with 21 liver malignancies (19 metastases, two primary liver tumors) were treated with interstitial CT-guided brachytherapy applying a (192)Ir source. In all patients, the use of image-guided thermal tumor ablation such as by radiofrequency or laser-induced thermotherapy (LITT) was impeded either by tumor size > or = 5 cm in seven, adjacent portal or hepatic vein in ten, or adjacent bile duct bifurcation in four patients. Dosimetry was performed using three-dimensional CT data sets acquired after CT-guided positioning of the brachytherapy catheters. RESULTS: The mean tumor diameter was 4.6 cm (2.5-11 cm). The mean minimal tumor dose inside the tumor margin amounted to 17 Gy (12-20 Gy). The proportion of the liver parenchyma exposed to > 5 Gy was 18% (5-39%) of total liver parenchyma minus tumor volume. Nausea and vomiting were observed in six patients after brachytherapy (28%). One patient demonstrated obstructive jaundice due to tumor edema after irradiation of a metastasis adjacent to the bile duct bifurcation. We commonly encountered asymptomatic increases of liver enzymes. Local control rates after 6 and 12 months were 87% and 70%, respectively. CONCLUSION: CT-guided brachytherapy is safe and effective. This technique displays broader indications compared to image-guided thermal ablation by radiofrequency or LITT with respect to tumor size or localization.     

Intracavitary high dose rate afterloading irradiation of inoperable malignant bile duct obstruction

After decompression of the bile duct with PTCD, seven patients with carcinomas of the bile ducts were submitted to an intracavitary Ir-afterloading irradiation performed according to the high-dose-rate method with a Buchler device. Most of the patients were irradiated with 30 Gy in two fractions. Five patients were also exposed to percutaneous radiation with 40 to 50 Gy. Local control was achieved in six patients. One patient developed a locoregional recurrence which was possibly due to a so-called "geographic miss". In one patient a benign fibrotic stenosis of the bile duct was found at the site of most intensive irradiation. Intracavitary irradiation is very important in the treatment of malignant obstruction of bile ducts. However, there is an urgent need of research with regard to the combined method with percutaneous irradiation and to the optimum fractionation of intracavitary high dose rate irradiation.     

Dose dependence effects of ionizing radiation on bile acid metabolism in the rat.

PURPOSE: To study radiation dose-related changes of individual or total bile acids in various physiological fluids in order to identify potential bio-indicators of radiation-induced gastrointestinal injuries. MATERIALS AND METHODS: Wistar rats were sham- or whole-body gamma irradiated (1-12Gy). Total and individual bile acids were quantified, 3 days after exposure, in bile collected after catheterization of the bile duct. Total bile acid concentrations were also measured in plasma and colonic contents 1, 2 and 3 days after irradiation. These concentrations were determined by an enzymatic method whereas individual bile acids were quantified by HPLC. RESULTS: In bile, whereas total bile acid concentration remained unchanged after irradiation whatever the dose, the proportion of dihydroxy bile acids in the pool of total bile acids was gradually increased with the irradiation dose, especially from 8 Gy. In plasma samples, total bile acid concentrations fell for doses higher than 10 Gy. In colonic contents, bile acid concentrations increased progressively with time (from 1 to 3 days) and with irradiation dose (from 1 to 12Gy), reaching a plateau 3 days after exposure for doses higher than 10 Gy. CONCLUSIONS: These results show that changes in colonic bile acid concentrations which are reflected in faeces are perhaps a useful parameter to improve diagnosis and prognosis of radiation-induced gastrointestinal damage since it probably reflects directly intestinal bile acid malabsorption.     

MRCP和US对肝外胆管病变诊断价值的对照研究

目的 :比较磁共振胆胰管水成像 (MRCP)和超声 (US)对胆总管病变的诊断价值 ;方法 :分析MRCP和US对 2 4例胆总管病变 (12例胆总管结石 ;12例胆总管肿瘤或肿瘤性病变 )诊断的敏感性和特异性。结果 :MRCP和US对 12例胆总管结石的诊断敏感性和特异性分别为 10 0 % (12 /12 )和 92 7% (11/12 ) ;对胆总管肿瘤或肿瘤性病变 ,MRCP诊断的敏感性和特异性为 10 0 % (12 /12 ) ;US的敏感性和特异性分别为 75 % (9/12 )和 75 % (9/12 )。结论 :MRCP和US诊断胆总管结石的敏感性和特异性差异无显著性意义 ;对胆总管下段肿瘤或肿瘤性病变MRCP优于US。     

Results of percutaneous transluminal irradiation of biliary tract carcinoma with 192Iridium

In 22 patients with bile duct carcinoma's intratumoral irradiation was performed through a percutaneous biliary drainage. 17 of them had been found to be inoperable at laparotomy, 5 others had recurrent carcinoma at the site of a biliodigestive anastomosis. The applied dose ranged from 60 to 80 Gy at 6 mm distance of the centre of the Iridium source. In 12/22 patients a clear reduction in the degree of tumor stenosis could be established. Regarding the survival of the patients (8.6 months) results were relatively poor, due to extensive metastases. Patients with a documented dilatation of tumor stenosis showed a low significant longer survival period (12.3 months) than those without detectable response (4.2 months).     

肝细胞癌合并胆管癌栓的影像表现

目的 探讨胆管癌栓的影像表现,以提高影像诊断水平.方法 回顾性分析经手术病理证实的肝细胞癌(HCC)胆管癌栓13例患者资料,其中3例进行了CT和MR检查,2例仅行CT检查,8例仅行MR检查,7例进行了MR胰胆管成像检查,13例均进行了超声检查.采用四格表Fisher 确切概率检验方法比较超声与CT、MR诊断HCC胆管癌栓的准确性.结果 13例HCC肿瘤及胆管癌栓均在CT或MRI上显示.4例胆管癌栓在CT上表现为胆管内软组织块影,动脉期可见癌栓轻度增强,癌栓远端胆管扩张.11例胆管癌栓在T1 WI上均呈稍低信号,T2 WI为稍高信号,增强后可见轻、中度强化.MR胰胆管成像上胆管癌栓表现为:胆管阻塞中断、狭窄或不规则充盈缺损伴有梗阻上方胆管扩张,胆管突然截断或呈"鼠尾"状(5例);肝内胆管扩张,癌栓充满整个胆总管.胆总管不显示(2例).超声检查准确诊断胆管癌栓7例,误、漏诊6例.CT、MRI准确诊断12例,误诊4例,超声与CT、MRI诊断胆管癌栓差异无统计学意义(P=0.270).结论 CT或MRI对诊断HCC合并胆管癌栓及明确癌栓范围有价值.     

Low-dose-rate teletherapy combined with hyperthermia as a boost therapy

The efficacy of the low dose rate teletherapy (LDRT; 1 Gy/hr, 4 Gy/day, 2-3 times/week) combined with hyperthermia as a boost therapy (H (+) group) against far advanced carcinomas was examined. The treatment results in H (+) group (17 esophageal carcinomas, 3 pancreatic and bile duct carcinomas and 5 other carcinomas) were compared with the ones in H (-) group (38 esophageal carcinomas, 5 pancreatic and bile duct carcinomas and 13 other carcinomas) which were treated with the LDRT (1 Gy/hr, 7 Gy/day, every day) as a boost. A total dose of 14-24 Gy by the LDRT was followed after the irradiation of 50-60 Gy by conventionally fractionated method (1.5-2 Gy/day). H (+) cases were treated with 42.5 degrees C, 1 hour hyperthermia immediately before the LDRT and 19 cases (76%) were successfully heated. There were no significant differences between H (+) group and H (-) group in local control, late severe complication and survival rates, even when they were corrected by primary sites and stages. The incidence of metastases was higher in H (+) group. It was considered that the gain of the combination of the LDRT and the hyperthermia as a boost therapy was a little.     

胆囊切除术中选择性胆道造影的应用价值

目的　探讨胆囊切除术中选择性胆道造影的应用价值。方法　回顾分析胆囊切除时选择性经胆囊管行胆道造影 3 9例的临床资料 ,根据传统观念这些病例均有胆总管探查的指征。结果　造影阳性 19例 ,其中结石征象 16例 ,胆总管下段狭窄 3例 ,阳性率 48.72 % ;手术探查阳性者 14例 ,其中胆总管结石 12例 ,胆总管下段炎性狭窄 1例 ,胆总管下段肿瘤 1例 ,造影准确率73 .68% ;手术探查阴性 5例 ,造影假阳性率 2 6.3 2 % ;造影阴性的 2 0例病人 ,未行胆总管探查而随访未发现异常。结论　选择性术中胆道造影安全方便 ,效果确切 ,对预防术中残留结石及因盲目胆总管探查而损伤胆道 ,减少术后并发症 ,提高胆囊手术质量有较好的应用价值     

Radiotherapy of postoperative residual tumor of bile duct carcinoma.

The case of a patient with bile duct carcinoma who had a postoperative residual tumor treated with high-dose-rate intraluminal brachytherapy (HDRIBT) following external radiotherapy is presented. Following radiotherapy, he has been alive and well without signs of recurrence for two years and eleven months as of this writing. HDRIBT following external irradiation is recommended for the treatment of postoperative small residual tumors of the bile duct.     

胆管内照射支架应用的实验研究

目的探讨实验犬胆管内照射支架置入的可行性和安全性。方法选择比格犬36只,分成实验组27只和对照组9只。实验组按放置粒子剂量分为A、B和C亚组,每组9只。A组每颗粒子剂量为11.1 MBq,放置2颗;B组为22.2 MBq,放置2颗;C组为33.3 MBq,放置2颗。采用经皮胆囊穿刺胆总管支架置入法,手术前后定期复查血液生化指标,并于术后2、4、6个月,各组分别取实验犬各3只,摄肝区平片、CT扫描及ECT粒子显像等影像方法观察内照射支架。实验犬处死后取支架及周围组织标本,分别行肉眼、光镜及电镜观察。结果 36只实验犬胆总管内照射支架均释放到位,释放过程顺利,未出现放射粒子脱落现象。术后复查血象和免疫指标未见明显变化。ECT复查未发现放射源泄漏。解剖实验犬未发现胆管穿孔、出血等并发症。6个月时实验组粒子附近胆管壁增厚最明显,与对照组比较差异有统计学意义(P<0.05),实验组的各亚组之间差异无统计学意义(P>0.05)。实验组和对照组胆总管内径在观察期内均表现为随时间延长管腔逐渐变窄,6个月时各实验组管腔内径与对照组比较差异无统计学意义(P>0.05)。6个月内实验组支架周围的肝脏、胰腺、门静脉及十二指肠与对照组肉眼、光镜所见基本一致。电镜下仅表现为胆管壁肌层增生、成纤维细胞增生等。结论实验犬胆总管内照射支架置入术可行、安全,其对犬胆管及其周围的正常脏器组织造成损伤轻微。     

MRI联合序列检查在壶腹周围癌鉴别诊断中的价值

目的 探讨MRI联合序列检查在壶腹周围癌(VPC)鉴别诊断中的价值.方法 回顾性分析53例经手术病理证实的VPC患者的MRI资料(壶腹癌17例、胰头癌15例、十二指肠乳头癌10例、胆总管下段癌11例),所有患者均行常规上腹部MRI平扫、磁共振胰胆管成像(MRCP)及多期动态增强扫描,重点观察分析肿瘤的形态学特征、动态强化特点、胰胆管形态学改变并测量相关数据.结果 4组VPC在大小、中心位置及信号均匀性方面总体存在差异性(P＜0.05),其动态强化特点也存在差别;VPC最常出现“双管征”(26/53),胰头癌易出现“四管征”(8/15),胆总管下段癌易出现“三管征”(8/11);“鸟嘴征”多见于壶腹癌(10/17),“鼠尾征”多见于胰头癌(7/15),“截断征”多见于胆总管下段癌(10/11);胰头癌组主胰管直径最大、胆总管下段癌组最小且其差异有统计学意义(P＜0.05);胰头癌组和胆总管下段癌组的胆总管梗阻末端及主胰管梗阻末端到十二指肠主乳头的距离、胰胆管汇合角度均大于壶腹癌组及十二指肠乳头癌组.结论 MRI联合序列检查能较好显示不同组织学来源VPC的影像学特征,综合分析这些特征有助于胰头壶腹区肿瘤组织学类型的鉴别.     

Pentoxifylline Enhances Tumor Oxygenation and Radiosensitivity in Rat Rhabdomyosarcomas during Continuous Hyperfractionated Irradiation

PURPOSE: To examine the influence of the hemorrheologic agent pentoxifylline (PTX) on tumor oxygenation and radiosensitivity. MATERIAL AND METHODS: Tumor oxygenation in rat rhabdomyosarcomas R1H after PTX administration (50 mg/kg body weight) was measured using interstitial pO(2) probes (Licox CMP system and Eppendorf pO(2)-Histograph). Tumors were irradiated with (60)Co gamma-irradiation using single doses (15 and 30 Gy), conventional fractionation (60 Gy/30 fractions/6 weeks), and continuous hyperfractionation (54 Gy/36 fractions/18 days) in combination with PTX or an equivalent volume of physiological saline. Radiation effects were determined by tumor growth delay (2V(o)), and by partial and complete tumor remission. RESULTS: PTX increased tumor oxygenation for up to 45 min after administration of the drug. Single doses of 15 and 30 Gy of irradiation, when combined with PTX, produced little radiosensitization of the R1H tumors as indicated by dose-modifying factors (DMFs) of 1.11 and 1.04, respectively. In conventional fractionated irradiation with PTX, a DMF of 1.10 was obtained only. However, in continuous hyperfractionated irradiation with 18 x 50 mg/kg of PTX, the DMF with respect to tumor growth delay was found to be 1.37. Local tumor control was not influenced by PTX. In vitro studies identified R1H cells as p53 wildtype and showed a G1 arrest in response to irradiation. When 2 mM PTX was given prior to irradiation, it did not improve radiosensitivity of R1H cells as measured by clonogenic survival assays. CONCLUSION: PTX effectively enhances tumor oxygenation and radiosensitivity of R1H rhabdomyosarcomas, especially during continuous hyperfractionated irradiation. Given to rats as an adjuvant to fractionated irradiation, PTX does not enhance acute or late skin reactions or tumor metastasis. No radiosensitization was observed in vitro, when oxygen was not limiting. The observed radiosensitization by PTX is caused mainly by improved tumor oxygenation.     

MR imaging findings of early bile duct cancer

Purpose

To retrospectively evaluate the MR imaging features of early bile duct cancer and to correlate them with the clinicopathologic findings.

Materials and Methods

This retrospective study was approved by our institutional review board, and informed consent was waived. Seventeen patients with surgically proven early bile duct cancer who had undergone preoperative MR cholangiopancreatography with gadolinium‐enhanced MR imaging, were included in this study. Two, experienced radiologists evaluated the MR images in consensus regarding the following findings: tumor number and morphology; signal intensity of the tumor; sharpness of the outer border of the bile duct wall; enhancement pattern of the tumor; and the presence of enlarged peribiliary lymph nodes. Another radiologist measured the SNR of the tumor and bile duct wall on gadolinium‐enhanced MRI during the dynamic phases to evaluate the tumor enhancement degree.

Results

In all patients, MR imaging demonstrated single or multiple intraluminal bile duct masses showing a sharply defined outer margin. The most common enhancement pattern of the biliary lesions showed heterogeneous amorphous enhancement or heterogeneous enhancement with central, dot‐like structures or vascular structures (76.5%, 13/17 patients). The difference of SNR between bile duct and tumor was greatest in the equilibrium phase (P < 0.05).

Conclusion

MRCP combined with dynamic contrast‐enhanced MRI can be useful for detecting early bile duct cancers. Common MR findings of early bile duct cancer include one or more inhomogeneously enhancing intraductal masses with clear outer margins and preservation of the bile duct wall. J. Magn. Reson. Imaging 2008;28:1466–1475. © 2008 Wiley‐Liss, Inc.     

Hepatocellular carcinoma with bile duct tumor thrombi: Correlation of magnetic resonance imaging features to histopathologic manifestations

Purpose

This study was to analyze the magnetic resonance imaging (MRI) features of hepatocellular carcinoma (HCC) with bile duct tumor thrombi, and explore their correlations to histopathology to improve the accuracy of diagnosis.

Materials and methods

21 patients with pathologically confirmed HCC with bile duct tumor thrombi was performed with a superconducting 1.5-T MR imager within two weeks before operation. Magnetic resonance cholangiopancreatography (MRCP) was performed on 18 patients. Images were retrospectively assessed for the size, location and MRI manifestations of HCC lesions and associated bile duct tumor thrombi. The differentiation of HCC lesions and the pathologic changes of bile duct tumor thrombi were retrospectively analyzed under microscope.

Results

The average diameter of HCC lesions was 5.8 ± 2.8 cm, and ≤5.0 cm in nine cases. Capsule formation was observed on MRI or pathology in 4 cases of HCC (19%). Of the 21 cases with bile duct tumor thrombi, 20 were clearly presented on MRI as cord-like or columnar masses in the bile duct with proximal cholangiectasis. The tumor thrombi showed slightly hypointense on T1WI and slightly hyperintense on T2WI. On enhanced scan, three cases of tumor thrombi, which were mainly consisted of necrotic tissue, did not show enhancement; 17 cases, which were mainly consisted of cancer cells, showed mild or moderate enhancement. On magnetic resonance cholangiopancreatogram (MRCP), 14 cases of tumor thrombi presented as filling defect in the bile duct, abrupt obstruction of the bile duct, and cholangiectasis above the obstruction; four presented as dilated intra-hepatic bile ducts with missing common bile duct. Of the 21 patients, 16 had biliary hemorrhage; three also had tumor thrombi in the portal vein. Seventeen of the 21 HCC with biliary thrombi were poorly differentiated, unencapsulated and with an invasive growth. Nineteen of 21 bile duct tumor thrombi did not invade the bile duct wall and could be easily extracted.

Conclusion

MRI plays a valuable role in diagnosing HCC with bile duct tumor thrombi and identifying the extent of the thrombi; the MRI features of HCC with bile duct tumor thrombi are associated with its pathologic changes.     

Primary carcinoid of the choledochus

The differential diagnosis of obstructive disease processes of the common bile duct can be very difficult even when sonography, endoscopic retrograde cholangiopancreatography (ERCP) and angiography are applied. In most cases, morphological changes are due to stones or carcinoma. We report on a case of a carcinoid tumor located in the intrapancreatic part of the common bile duct. Exact localization, delineation and demonstration of the local extension of such a tumor requires at least ERCP and angiography, as these are the most efficient imaging techniques for these purposes.     

经皮胆囊管悬吊法在腹腔镜经胆囊管行胆总管探查手术中的应用研究

目的：探讨经皮悬吊胆囊管在腹腔镜经胆囊管胆总管探查术中的临床应用。方法：对24例造影证实胆囊结石并发胆总管结石患者行腹腔镜胆囊切除术,术中悬吊胆囊管,并经胆囊管行胆道镜胆总管取石。结果：24例患者均顺利取出结石,无胆漏、感染及胰腺炎等并发症,随访3～32月无结石复发。结论：通过经皮悬吊胆囊管可以提高腹腔镜经胆囊管胆总管取石术成功率,相对缩短手术时间,同时安全、有效。     

Pseudo-obstruction of the extrahepatic bile duct due to artifact from arterial pulsatile compression: a diagnostic pitfall of MR cholangiopancreatography

PURPOSE: To evaluate the frequency of artifact from arterial pulsatile compression as the cause of pseudo-obstruction of the extrahepatic bile duct at magnetic resonance (MR) cholangiopancreatography (MRCP) and specify the causative vessels. MATERIALS AND METHODS: In 234 patients (102 men, 132 women; age range, 25-80 years), MRCP images obtained by using a single-shot turbo spin-echo sequence were reviewed to assess pseudo-obstruction of the extrahepatic bile duct caused by vascular compression. Dual-phase spiral computed tomography, contrast material-enhanced three-dimensional MR angiography, and/or digital subtraction angiography also were performed to determine the vessel that caused the pseudo-obstruction. RESULTS: Thirty-six pseudo-obstructions due to vascular compression were found in 33 (14%) patients. The common hepatic duct (27 [75%] sites) was the most common pseudo-obstruction site, followed by the left hepatic duct (four [11%] sites), proximal common bile duct (three [8%] sites), and right hepatic duct (two [6%] sites). The causative vessels were identified as the right hepatic artery at 24 (67%) sites; gastroduodenal artery, two (6%) sites; cystic artery, two (6%) sites; proper hepatic artery, one (3%) site; and an unspecified branch of the common hepatic artery, seven (19%) sites. CONCLUSION: At MRCP, pseudo-obstruction of the extrahepatic bile duct can be caused by pulsatile vascular compression of the hepatic and gastroduodenal arteries, and it should not be misdiagnosed as a bile duct tumor or biliary stone.     

The value of radiation therapy in the management of adenoid-cystic carcinoma of the head and neck

There are different opinions about the importance of radiotherapy in the treatment of adenoid-cystic carcinomas. A report is given on the experiences gained with highdose radiotherapy in twelve patients suffering from adenoid-cystic carcinomas. In spite of the unfavorable composition of the group of patients (6/12 were classified stage T3 or T4, 5/12 were only irradiated after a local recurrence had appeared), local tumor control was achieved in all patients by percutaneous irradiation with a focal dose of 80 Gy or interstitial irradiation with a focal dose of 70 Gy. On the basis of these results as well as of recent communications in literature, it is concluded that adenoid-cystic carcinomas can be locally cured by radiotherapy.     

3.0T磁共振钆塞酸二钠磁共振胆管造影术在胆管疾病中应用

目的探讨3.0T磁共振钆塞酸二钠(Gd-EOB-DTPA)磁共振胆管造影术(MRC)在胆管疾病中的诊断价值。方法选取2016年7—12月解放军309医院收治的20例患胆道梗阻或其他病变需行Gd-EOB-DTPA MRC检查的患者,采用3.0T超导磁共振扫描仪,对所有20例患者行常规上腹部平扫+磁共振胰胆管造影(MRCP)+Gd-EOB-DTPA动态增强扫描,以及肝胆特异期、T1容积内插体部检查(VIBE)冠状位+轴位扫描,并将冠状位图像进行最大密度投影(MIP)重建,获得胆管树图像。对各序列的影像学特征做出诊断,并与穿刺、手术病理、内镜下逆行胰胆管造影术及相关临床资料进行对照。结果本组20例患者中,胆管解剖变异者7例。其中,胆囊管经胆总管前方汇入胆总管左侧壁1例,经胆总管后方汇入胆总管左侧壁3例,胆囊管开口于肝外胆管下1/3处2例,胆囊管汇入右肝管1例。胆管梗阻11例,其中,完全性梗阻8例(肝门部胆管恶性占位5例、胆总管恶性占位1例、胆总管下端结石1例,胆总管周围淋巴结转移1例);部分梗阻3例(胰头占位1例,胆总管结石1例,胃窦癌侵及胆总管1例)。胆漏2例。硬化性胆管炎1例。其中,1例患者同时有胆漏及胆囊管汇入右肝管变异。结论 Gd-EOB-DTPA MRC检查能够直接显示肝内外胆管系统解剖结构以及胆管通畅情况,能为胆管疾病的诊断提供更多的信息,可以进一步应用于胆管疾病的检查。